The patient's behaviour is a pivotal factor in the success of any healthcare intervention but it seems that an understanding of how patients really behave is often missing from healthcare strategy, planning and intervention design. This blog will discuss some of what we already know can make a difference, some of what I think will help, and some of the obstacles to change that we need to deal with.
I focus on the analysis and design of healthcare systems and intervention programmes aimed at changing patient behaviour for better health outcomes. I have more than three decades of experience in applied health psychology research and practice with clients in the public sector and the health technology, pharma and insurance industries.

03/04/2013

Falling By The Wayside On The Pathway To Better Health

Patients can
easily slip off the path to better health. Where, how and why? What can be
done?

Scenario:
you have a disease.

How do you
know?

Your mama told you what to watch out for?

Your friend/partner says, “That ain’t right. You
should see someone about that”?

You Googled that funny sensation?

The clinic found it at your annual check-up?

It’s OK, you won’t have a disease. You never get
sick. (Good luck with that).

Now what?

Pray for the strength and wisdom to accept the
will of God?

Make an appointment with the doctor/osteopath/naturopath/faith
healer?

Go immediately to the E.D.?

It’s probably nothing serious. Just wait and see
if it gets better?

Google it?

You decide that to get better, you need the correct diagnosis
and an effective treatment. Your doctor/naturopath/faith healer/Dr. Google
knows what they are talking about, right? And you believe them? And you
understand and can afford to do what they suggest? And you will actually follow
their advice, won’t you?

If you are justifiably confident on all those points, good
for you — but you are probably an exception. Research published by the World
Health Organisation found that between 24% and 62% of people in seven different
countries have diabetes that is undiagnosed and untreated. Even for those
diagnosed, treatment goals were achieved by no more than 12% of individuals.
Some developed countries, such as England and Scotland, were among the worst
performers[1].

Figure 1 tracks the pathway from onset of a disease to its
outcome. One thing stands out in this: the patient’s behaviour is as pivotal in
influencing outcome as anything the healthcare system does.

Figure 1. The healthcare pathway from disease to outcome

For a disease to be presented for diagnosis, the symptoms of
the illness have to be recognised as requiring healthcare attention — usually
the patient (or someone close to them) is in the best position to notice these
symptoms.

And yet the American Heart Association reported that 50% of
people in the United States suffering an acute myocardial infarct die in or
before reaching an emergency department or hospital[2]. The report notes:

After the patient has presented for healthcare, the quality
and timeliness of diagnosis remains significantly dependent on their
behaviour. They need to truthfully and
accurately report their concerns, cooperate with investigations and re-present as
required for further assessment, diagnosis and management.

But patients routinely obscure and distort the facts of
their illness to their doctors[3].
Many do not complete the monitoring procedures requested[4]
and do not follow treatment recommendations, both pharmacological and otherwise[5].

It is hardly surprising that it can be difficult to
replicate clinical trial results in real-life practice[6].

From a healthcare point-of-view grounded in bio-science, it
makes little sense for patients to jeopardise their future health in these
ways. And yet, healthcare workers trained in bio-science behave in all the same
ways themselves when they are in the patient role, underlining the American
Heart Association report comment on the power of social and emotional drivers,
at least.

Some of the factors that probably shape these behaviours:

Health literacy

Knowledge of disease symptoms and signs

Understanding of where and how to seek
appropriate care

Understanding of information and advice received

Decision-making skills and ability to negotiate
with the healthcare system

Health beliefs and expectations

Concerns about the specific disease and its
treatment

Expectations about disease timeline (acute vs
chronic)

Perceived necessity of treatment

Tolerance of ill-health

Culture and values

Determinants of disease and prognosis (fate vs
will of God vs science)

But there is so much to do here. Where on earth do we in
healthcare start?

Well, I think we can do some whittling of the list fairly
quickly.

Social security lies beyond the realms of
healthcare. Healthcare is a very expensive and inefficient place to deliver
remedies for social dis-ease. That is not what healthcare professionals are
trained to do or motivated to do and directing them to do it is a misallocation
of resources.

Health literacy is a product of education and socialisation.
The education system is probably much better positioned than the healthcare
system to get results here.

Culture and values are phenomena that emerge
from an obscure morass of influences that can only be shaped over long time
periods, to the extent that they can be deliberately shaped at all. Healthcare
operates on a much shorter time scale.

I am not suggesting that these three categories of drivers
of health-related behaviour are unimportant – quite the contrary. But they are
not within the power of healthcare to fix.[7]

That leaves the psychological drivers – beliefs,
expectations, affect and coping. There are already well-established strategies
and interventions within healthcare for addressing these and some promising applications
of technology such as text-messaging[8]
and the internet[9]
to make them available to large numbers of people.

Progress in this area has been remarkable considering the
comparative lack of investment[10]
and there is much room for increasing knowledge and capability[11].
By investing both in the development of new knowledge and skills and the
implementation of what we already know, we may gain a great deal more value
from past and future investment in the bio-science basis of healthcare.

[7]
I see little alternative than for government to take responsibility for
developing a policy framework across economics, education and social welfare
that promotes a society that enhances the well-being of all its citizens. The
healthcare and justice systems are the indicators of how well these policies
are working.

[10]
For example, the US National
Institute of Health allocates less than 5% of its research budget to
behavioural and social sciences. FY2011 Directors Overview. National Institute
of Health. Page OD-9. Downloaded from officeofbudget.od.nih.gov/pdfs/FY11/FY%202011%20OD%20CJ%20508%20compliant.pdf.

Comments

You can follow this conversation by subscribing to the comment feed for this post.

The comments to this entry are closed.

Grant Taylor
Director, Taylor Health Design

With a professional background as a clinical psychologist and health psychologist, I have more than 30 years of experience in healthcare service delivery, intervention design, organisational development and leadership - most recently Director of the intervention design and R&D teams at a leading, multinational provider of medication adherence and patient support programmes. I believe strongly in the importance of patient behaviour as a determinant of healthcare outcomes.

How can we design health service systems and interventions that better match what patients are really like and thereby deliver better healthcare outcomes and better returns on investment?

This blog discusses some of what we already know can make a difference, some of what I think will help, and some of the obstacles to change that we need to deal with. Please join the discussion: add your comments, subscribe to the feed or email me directly.